Table 25

Investigation and management of nausea

Investigations	Potential results	Clinical management plan
Actions from history, medication and dietary assessment
History findings	Symptoms of heart burn/acid/bile reflux	See management of acid or bile related inflammation (p. 25). Reassess after 2–4 weeks as clinically indicated.
	With dizziness/sweating/palpitations	See page 20.
	Headache/neurological symptoms present	Neurological examination. Funduscopy and CT/MRI head.
	Poor fluid intake	Check renal function/encourage fluids.
	Constipation/impaction	AXR. See management of constipation (p. 26).
Medication findings	Opiates NSAID
	Chemotherapy	Contact team to change antiemetics urgently. If multiple vomiting daily this is an emergency. Contact the on-call acute oncology team.
Dietary findings	Nutritional compromise	Refer for dietetic advice.
First line
Funduscopy	Raised ICP	This is an emergency. Discuss immediately with the supervising clinician and oncology or neurology team.
Routine and additional blood tests	Metabolic abnormality	Discuss immediately with the supervising clinician.
	Liver/biliary abnormality	Discuss with the supervising clinician within 24 hours.
	Suggestive of infection	Treat with antibiotics within level of confidence or discuss with microbiologist or supervising clinician.
Urine analysis	Metabolic abnormality, eg, glucosuria, ketonuria	Discuss immediately with supervising clinician.
	Infection	Treat with antibiotics within level of confidence or discuss with a microbiologist or supervising clinician within 24 hours.
Second line
OGD and SI aspirate (p. 25)	Upper GI inflammation/ulceration	See management of acid or bile related inflammation (p. 25).
	Gastric dysmotility	Consider prokinetic medication (p. 26).
	Pyloric stenosis	Refer urgently to the appropriate cancer MDT.
	Bleeding peptic ulcer	This is an emergency. Discuss immediately with the supervising clinician/gastroenterologist.
	SIBO	Management of SIBO (p. 27).
Glucose hydrogen methane breath test	SIBO	Management of SIBO (p. 27).
US liver and pancreas	Biliary/hepatic/pancreatic aetiology	See management of jaundice on p. 18.
Cortisol level	Addison's disease	Confirm with the Synacthen test, start on hydrocortisone and refer to endocrinology.
US/CT/MRI/PET	Malignancy/tumour recurrence/lymphadenopathy	Discuss and refer urgently to the appropriate cancer MDT requesting an appointment within 2 weeks.
	Consider also Internal hernia (if Roux-en-Y) Jejunal tube complication, eg, volvulus (if still in situ) Pancreatitis	These are emergencies. Refer to upper GI surgical team.
	Mesenteric ischaemia	This is an emergency. Discuss with the on-call surgical team immediately.
	Ascites	Discuss with the supervising clinician and the oncology team within 24 hours.
Third line
If normal investigations/no response to intervention		Consider contributing psychological factors. Consider referral for psychological support if there is a possible underlying eating disorder. Consider a routine referral to gastroenterology for further management.

AXR, abdominal X-ray; CT, computerised tomography; GI, gastrointestinal; ICP, intracranial pressure; MDT, multidisciplinary team; NSAID, non-steroidal anti-inflammatory drug; OGD, upper GI endoscopy (oesophago-gastroduodenoscopy); PET, positron emission tomography; SIBO, small intestinal bacterial overgrowth; US, ultrasound.